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COntlrierCe.WI.JOV Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 lin r A <br /> tDispartnaint of C��ms• Madison,WI 53707-7162 Sanitary Permit Number(m be filled N by Co.) <br /> iscons�n ,SNP &I <br /> State Transaction Number <br /> Sanitary Permit Application -in accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of tris form to the appropriate governmental /� <br /> mut is required prior m obtaining a sanitary peanut. Note: Application forms for smmowned POWTS are Project Address(if different than mailing address) �J 1 <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondarypuipo <br /> ees in accordance with the Priv3cy Law,a.15. l)m),Stab. Tele., Greer,( <br /> L A tiatim Information-Please Print Ali Wortnatim Parcel9 <br /> Property Owner's Name ( 9 <br /> 1?—,6 e.-'l- IV i r6ro�v%. Wet;-;A 4LO Ol t4- a a. <br /> Property Owner's Mailing Address Property Location <br /> /7j S5 meo,Av Vlsw 1?d Govt Lot <br /> City,State Zip Code Phone Number 50 Yy_tj k)Yy Section 3 N <br /> rh h/ NN3y (rack one <br /> LCA 4r T?,�_N; R /.f Eo <br /> IL T of Building(check all that aPP1Y) Lot p <br /> YPe � Subdivision Name <br /> 1 or 2 Family Dwelling-Number of Bedrooms <br /> Block 9 <br /> ❑PubEdCommercial-Describe Use ❑ City of <br /> CSM Number ❑Village of <br /> ❑Stam owned-Describe Use Town of Z 0 Fo Ile?Ke- <br /> -------------------------- <br /> 111. <br /> /CIDL Type of Permit: (Check onlY oro box on lkn A. Complete tine B if applicable) <br /> ]A21;Nm System ❑Replacement System ❑Trcatment/Holding Tank ReplacementOnly ❑Other Modification m Existing System(explain) <br /> it Renewal ❑Permit Revision ❑ChangeofPlumber ❑Pen°itTransfermNew <br /> List Preview Permit Number and Dam Issued <br /> xpiration aver <br /> IV.Type of POWTS stetn/Con onent/Device: Check all that apply) <br /> NNom-Pressmized In-Cmound [1Pressurized In-Cnound LlAt'Gmde C1 Mound>_ht in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holdimg Tank ❑OthcrDispersal Component(esplam) ❑Preteatmeat Device(explain) <br /> V. ersal/rreahnent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 4S-o . S 900 900 if 93• r <br /> VI.Tank Info Capacity in Total k of Manufacturer I o <br /> Gaaow Gallons Units a ' rj <br /> w 8 u b <br /> f a <br /> New Tanks fiximing Tacks �' g in <br /> Sepuc a Ho1dmBTauk //B or 0 10//0--0 <br /> Dmvrg Clarnber ;600 &-e <br /> VII.ResponsibilityStatement-I,the undersigned,assume responsibility for installation of the POWTS shown the attached Bans.. a one Number <br /> Plumber's Name(Print)�/ Plumber's Signature <br /> Plumber's Address(Street,City,state,zip Code) <br /> x17760 7Vw �-4`1w�`sfr✓ Il/L' S�1893 <br /> VIIL Cam /De artment Use Ont <br /> Permit Fee DateIssuedIeauhrg Signature <br /> Approved ❑Disapproved <br /> ❑Gwncr Given Reason forIenial <br /> IX.Conditions of ApprovaUReasons fm Disapproval <br /> Amchm mmprkh phmfor tla system amt mbdt m the Courcy am1Y m perp•'mol les thea 8[2:11 Imehes ti site <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />